四肢骨肿瘤微波消融治疗临床指南

微波消融治疗四肢骨肿瘤已有三十余年历史。近年来,随着认识水平的提高、微波设备的改进及临床应用的拓展,微波消融技术被广泛应用于骨肿瘤的治疗。为了更好地规范微波消融技术在四肢骨肿瘤临床治疗中的应用,总结微波消融治疗四肢骨肿瘤的研究成果和临床经验,特制定本临床指南。旨在通过循证医学的方法,从经皮微波消融四肢骨肿瘤和术中微波消融四肢骨肿瘤两个方面,对适应证、术前评估与决策、围手术期处理、并发症等临床问题提供可靠的依据,从而规范治疗流程,提高微波消融四肢骨肿瘤的临床疗效。指南共形成推荐意见22条,第1条至第6条为经皮微波消融治疗四肢骨肿瘤的推荐意见,具体内容包含经皮微波消融四肢骨肿瘤适应证的选择、影像引导技术、麻醉技术、微波消融参数及治疗目标;第7条至第20条为术中使用微波消融治疗四肢骨肿瘤的推荐意见,具体内容包含术中微波消融四肢骨肿瘤适应证的选择、消融原则、消融技术、消融并发症及其他需要关注的问题;第21条至第22条为微波消融设备的选择与应用。     

微波消融联合骨水泥注射治疗脊柱附件转移瘤

目的 探讨微波消融联合骨水泥注射治疗脊柱附件转移瘤的疗效。方法 2017年3月～2021年11月，对32例脊柱附件转移瘤行微波消融联合骨水泥注射。共49个脊柱附件溶骨性病变(17例单发，15例多发),在CT引导下行微波消融联合骨水泥注射。观察术后病变附件影像学变化；术后1周、3个月、6个月、12个月用视觉模拟评分(Visual Analogue Scale, VAS)评估疼痛缓解程度；术后1年用日常生活能力量表(Activity of Daily Living Scale, ADL)评估生活质量。结果 32例手术均顺利，1例病椎附件骨水泥渗漏，无椎管内渗漏和肺栓塞等并发症。术后1周、3个月、6个月、12个月VAS评分均低于术前(P<0.05);术后1年ADL评分高于术前(P<0.05)。术后1年时，1例2个附件肿瘤进一步浸润并突入椎管内，1例1个附件肿瘤侵入相邻椎体内，其余附件及椎体未见肿瘤进一步浸润侵袭。结论 微波消融联合骨水泥注射治疗脊柱附件转移瘤安全可行，具有良好的止痛效果，能够显著改善生活质量，并可维持脊柱附件完整，同时延缓椎管内和椎体内肿瘤浸润。     

中国骨关节炎疼痛管理临床实践指南(2020年版)

骨关节炎(osteoarthritis,OA)是常见的关节疾病。疼痛是OA患者就医的首要主诉,因此有必要对OA的疼痛管理进行规范。本指南的制订过程参考世界卫生组织推荐的指南制订方法。由多学科专家组成指南制订小组,通过多轮针对临床医生的在线问卷调研确定指南中需要定义的重要临床问题。对OA领域已发布的相关指南、系统评价以及临床随机对照研究进行文献综述,并对相关证据进行评价。经过多轮德尔菲投票确定指南的推荐意见及其推荐强度。最终形成14条推荐意见,涉及OA疼痛管理的非药物治疗(运动治疗、健康教育、体重管理等)和药物治疗(外用及口服非甾体抗炎药、度洛西汀、关节腔药物注射等)多方面干预措施。以期为我国OA疼痛管理的实践提供临床指导和帮助。     

中国儿童及青少年初次创伤性髌骨脱位诊疗指南(2024年版)

初次创伤性髌骨脱位(first-time traumatic patellar dislocation, FTPD)是一种常见的儿童及青少年运动损伤, 近年来发病率有逐渐升高的趋势。国内骨科医生对儿童及青少年FTPD的诊疗水平也有了长足的进步, 但尚未达成一致的共识。本指南由首都医科大学附属北京积水潭医院(国家骨科医学中心)、中华医学会小儿外科分会小儿骨科学组及中华医学会骨科分会小儿创伤与矫形学组发起, 采用推荐意见分级的评估、制订及评价分级体系和国际实践指南报告标准, 基于文献证据评估形成8条推荐意见。推荐条目1～2为儿童及青少年FTPD发生的危险因素及病理解剖特点, 条目3～8为FTPD手术治疗的原则。指南旨在提高儿童及青少年FTPD诊疗的科学性, 最终提升以患者为中心的医疗服务质量。     

中国血友病骨科手术围手术期管理指南

血友病相关骨科疾病主要包括关节内出血、慢性滑膜炎、软组织畸形、血友病性假瘤、病理性骨折及跟腱挛缩。血友病相关骨科疾病在凝血因子替代治疗下可以采用手术治疗, 但血友病骨科手术不同于常规手术, 围手术期凝血因子的替代方案、手术适应证的掌握、术中操作、术后管理、功能训练与康复, 以及凝血因子抑制物的检测等均可影响手术效果。中华医学会骨科学分会关节外科学组和中国血友病协作组在2016年版《中国血友病骨科手术围术期处理专家共识》的基础上结合当前的循证医学证据, 采用Delphi法问卷调查的形式, 制订了《中国血友病骨科手术围手术期管理指南》, 详细阐述了截骨矫形术、人工关节置换术、关节融合术、截肢术等血友病相关骨科手术的适应证、手术原则和注意事项, 最终形成17条推荐意见, 旨在更好地指导临床实践, 进一步规范血友病骨科手术的围手术期管理。     

中国膝关节周围截骨下肢力线矫正术治疗膝关节骨关节炎临床指南

单间室膝关节骨关节炎(osteoarthritis, OA)是膝关节退变的早期阶段, 表现为膝关节单一间室退变, 多发生于内侧间室, 主要症状为膝关节疼痛和活动受限, 影响患者生活质量。对于伴有力线异常的单间室膝关节OA, 膝关节周围截骨下肢力线矫正术是有效的治疗方式之一。通过调整下肢力线, 将压力从患侧间室转移至正常间室或正常力线位置, 从而缓解膝关节疼痛, 改善膝关节功能。目前尚无膝关节周围截骨下肢力线矫正术治疗单间室膝关节OA的临床指南。经中国医院协会临床新技术应用专业委员会、中华医学会骨科学分会关节外科学组和中国医师协会骨科医师分会骨关节炎学组的专家共同讨论, 采用推荐意见分级的评估、制订及评价(Grading of Recommendations Assessment, Development and Evaluation, GRADE)分级体系和卫生实践指南报告标准(Reporting Items for Practice Guidelines in Healthcare, RIGHT), 遴选出骨科医生最为关注的25个问题, 先后通过证据检索、证据体质量评价以及确立推荐意...     

中国髌股关节骨关节炎诊疗指南(2020年版)

髌股关节骨关节炎(patellofemoral osteoarthritis,PFOA)是膝关节骨关节炎的一种重要亚型,人群患病率高、疾病负担重。既往膝关节骨关节炎临床诊疗指南主要针对胫股关节骨关节炎制订,而近年来PFOA受到越来越多的关注,因此有必要对PFOA的临床诊断和治疗进行规范。本指南制订小组由骨科临床专家组成,采用世界卫生组织推荐的指南制订方法,通过多轮针对临床医生的在线问卷调研确定指南中需要定义的重要临床问题;而后针对PFOA领域已发表的相关系统评价、临床试验以及观察性研究进行文献综述,并对相关证据进行质量评价;经过多轮德尔菲法投票确定指南的推荐意见及其推荐强度;最终形成了12条推荐意见,涵盖PFOA的诊断(症状、体征和影像学改变)、非手术治疗(基础治疗和药物治疗)以及手术治疗(修复性手术和重建手术)等管理措施。本指南旨在为我国PFOA的临床诊疗实践提供指导和帮助。     

胆道肿瘤临床实践指南（英文第三版）

日本肝胆胰外科学会（JSHBPS）于2007年出版第一版胆道肿瘤（胆管癌、胆囊癌及壶腹癌）临床实践指南,于2014年更新第二版,2021年英文第三版胆道肿瘤临床实践指南围绕6个主题提出若干临床问题,基于相关循证医学证据并组织专家讨论后,最终确定推荐意见、推荐强度以及推荐说明。根据证据推荐分级的评估、制订与评价（GRAD...     

腰椎间盘突出症诊疗指南

腰椎间盘突出症是骨科常见疾病,人群发病率高。随着社会发展和生活方式的改变,腰椎间盘突出症的发病率呈现逐渐增高的趋势。鉴于腰椎间盘突出症诊疗理念和技术手段的不断进步,有必要对腰椎间盘突出症的诊断和治疗方法进行总结和规范其诊疗流程。本指南遵循循证医学的原则,参照2013年我国卫生行业科研专项项目制订的《腰椎间盘突出症诊疗指南专家共识及临床路径》和2013年北美脊柱外科学会制订的《腰椎间盘突出症伴神经根病诊疗指南》,经过指南注册及指南计划书撰写、组建指南制订专家工作组及确定临床问题;参照证据推荐分级的评估、制订与评价工作组相关方法进行检索文献的证据等级和推荐等级评定,形成推荐意见;经专家工作组三轮讨论,最终确定终稿。指南从腰椎间盘突出症的定义、自然病程、症状和体征、辅助检查、诊断标准、保守治疗、手术治疗、手术疗效评估、手术效果的影响因素等方面阐述了腰椎间盘突出症的诊疗措施,以期为腰椎间盘突出症的诊断和治疗提供可靠的临床理论依据。     

原位微波消融在侵及骨组织的软组织肿瘤保肢手术中的初步应用

目的探讨原位微波消融技术在侵及骨组织的软组织肿瘤保肢手术中的应用价值。方法对2009年3月-2011年8月收治的10例侵及骨组织的恶性或交界性软组织肿瘤患者结合原位微波消融技术进行保肢手术,术后3个月按骨与软组织肿瘤协会（Musculoskeletal Tumor Society,MSTS）评分评估术后肢体功能,观察随访期间局部复发及周身转移情况。结果 10例病例全部获得随访,平均随访时间8.9个月（3～25个月）。保肢手术全部成功,MSTS评分上肢1例27分,下肢9例平均25分（16～30分）。优良率为90%。术后3、17个月局部复发各1例,肺部转移2例。其中1例复发伴肺转移患者截肢术后3个月死亡,余2例末次随访时均带瘤生存。结论在严格掌握手术适应证的基础上对侵及骨组织的软组织肿瘤施行结合原位微波消融技术的保肢手术,可以在未增加复发率的情况下降低手术操作难度,提高成功率,初步临床效果满意。     

Clinical Guideline for Microwave Ablation of Bone Tumors in Extremities

Microwave ablation has been used to treat bone tumors in extremities for more than 30 years. With improved recognition, updated microwave equipment, and expanded clinical application, microwave ablation has recently been widely used to treat bone tumors. To standardize the application of microwave ablation in the clinical treatment of bone tumors in the limbs, research results and clinical experience involving the use of microwave ablation to treat bone tumors in the limbs have been summarized, and a clinical guideline has been designed. This guideline is aimed at providing a reliable clinical basis for indications, preoperative evaluation and decision‐making, perioperative treatment, complications, and other issues via evidence‐based medicine. Two aspects are considered—percutaneous microwave ablation and intraoperative microwave ablation of bone tumors in extremities. Ultimately, the guideline is intended to standardize treatment and improve the clinical efficacy of microwave ablation of bone tumors in extremities.     

中国老年骨质疏松症诊疗指南（2018）

根据国内外循证医学指南制定标准化方法与步骤,组建多学科指南制定专家工作组,先后经过指南注册及指南计划书撰写、相关指南评价分析、临床问题遴选和确定、临床证据检索及评价、形成推荐意见等流程,经共识专家组3轮讨论,最终制定中国老年骨质疏松症诊疗指南(2018)。使用GRADE系统对证据体和推荐意见进行分级。同时考虑中国患者的偏好与价值观、干预措施的成本和利弊平衡为老年骨质疏松症的诊疗提供15条推荐意见。该指南涵盖了老年骨质疏松症的筛查、风险评估、诊断、基础措施、多种抗骨质疏松药物、疗效监测和评估等方面。本指南旨在为我国广大临床医生和患者提供科学依据。     

An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update)

Background contextThe evidence-based clinical guideline on the diagnosis and treatment of degenerative lumbar spinal stenosis by the North American Spine Society (NASS) provides evidence-based recommendations to address key clinical questions surrounding the diagnosis and treatment of degenerative lumbar spinal stenosis. The guideline is intended to reflect contemporary treatment concepts for symptomatic degenerative lumbar spinal stenosis as reflected in the highest quality clinical literature available on this subject as of July 2010. The goals of the guideline recommendations are to assist in delivering optimum efficacious treatment and functional recovery from this spinal disorder.PurposeProvide an evidence-based educational tool to assist spine care providers in improving quality and efficiency of care delivered to patients with degenerative lumbar spinal stenosis.Study designSystematic review and evidence-based clinical guideline.MethodsThis report is from the Degenerative Lumbar Spinal Stenosis Work Group of the NASS's Evidence-Based Clinical Guideline Development Committee. The work group consisted of multidisciplinary spine care specialists trained in the principles of evidence-based analysis. The original guideline, published in 2006, was carefully reviewed. A literature search addressing each question and using a specific search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology), and four additional, evidence-based, databases to identify articles published since the search performed for the original guideline. The relevant literature was then independently rated by a minimum of three physician reviewers using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final recommendations to answer each clinical question were arrived at via work group discussion, and grades were assigned to the recommendations using standardized grades of recommendation. In the absence of Levels I to IV evidence, work group consensus statements have been developed using a modified nominal group technique, and these statements are clearly identified as such in the guideline.ResultsSixteen key clinical questions were assessed, addressing issues of natural history, diagnosis, and treatment of degenerative lumbar spinal stenosis. The answers are summarized in this document. The respective recommendations were graded by the strength of the supporting literature that was stratified by levels of evidence.ConclusionsA clinical guideline for degenerative lumbar spinal stenosis has been updated using the techniques of evidence-based medicine and using the best available clinical evidence to aid both practitioners and patients involved with the care of this condition. The entire guideline document, including the evidentiary tables, suggestions for future research, and all references, will be available electronically at the NASS Web site (www.spine.org) and will remain updated on a timely schedule.     

Clinical Guideline for Treatment of Symptomatic Thoracic Spinal Stenosis

Thoracic spinal stenosis is a relatively common disorder causing paraplegia in the population of China. Until nowadays, the clinical management of thoracic spinal stenosis is still demanding and challenging with lots of questions remaining to be answered. A clinical guideline for the treatment of symptomatic thoracic spinal stenosis has been created by reaching the consensus of Chinese specialists using the best available evidence as a tool to aid practitioners involved with the care of this disease. In this guideline, many fundamental questions about thoracic spinal stenosis which were controversial have been explained clearly, including the definition of thoracic spinal stenosis, the standard procedure for diagnosing symptomatic thoracic spinal stenosis, indications for surgery, and so on. According to the consensus on the definition of thoracic spinal stenosis, the soft herniation of thoracic discs has been excluded from the pathological factors causing thoracic spinal stenosis. The procedure for diagnosing thoracic spinal stenosis has been quite mature, while the principles for selecting operative procedures remain to be improved. This guideline will be updated on a timely schedule and adhering to its recommendations should not be mandatory because it does not have the force of law.     

Degenerative lumbar spinal stenosis: an evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis.

BACKGROUND CONTEXT: The objective of the North American Spine Society (NASS) evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (DLSS) is to provide evidence-based recommendations to address key clinical questions surrounding the diagnosis and treatment of DLSS. The guideline is intended to reflect contemporary treatment concepts for symptomatic DLSS as reflected in the highest quality clinical literature available on this subject as of April 2006. The goals of the guideline recommendations are to assist in delivering optimum, efficacious treatment, and functional recovery from this spinal disorder. PURPOSE: To provide an evidence-based tool that assists practitioners in improving the quality and efficiency of care delivered to patients with DLSS. STUDY DESIGN/SETTING: Evidence-based clinical guideline. METHODS: This report is from the Spinal Stenosis Work Group of the NASS Clinical Guidelines Committee. The work group comprised medical, diagnostic, interventional, and surgical spinal care specialists, all of whom were trained in the principles of evidence-based analysis. In the development of this guideline, the work group arrived at a consensus definition of a working diagnosis of lumbar spinal stenosis by use of a modification of the nominal group technique. Each member of the group formatted a series of clinical questions to be addressed by the group and the final list of questions agreed on by the group is the subject of this report. A literature search addressing each question and using a specific literature search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology), and four additional, evidence-based, databases. The relevant literature to answer each clinical question was then independently rated by at least two reviewers using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Any discrepancies in evidence levels among the initial raters were resolved by at least two additional members' review of the reference and independent rating. Final grades of recommendation for the answer to each clinical question were arrived at in face-to-face meetings among members of the work group using the NASS-adopted standardized grades of recommendation. When Levels I to IV evidence was insufficient to support a recommendation to answer a specific clinical question, expert consensus was arrived at by the work group through the modified nominal group technique and is clearly identified as such in the guideline. RESULTS: Eighteen clinical questions were asked, addressing issues of prognosis, diagnosis, and treatment of DLSS. The answers to these 18 clinical questions are summarized in this document along with their respective levels of evidence and grades of recommendation in support of these answers. CONCLUSIONS: A clinical guideline for DLSS has been created using the techniques of evidence-based medicine and using the best available evidence as a tool to aid both practitioners and patients involved with the care of this disease. The entire guideline document including the evidentiary tables, suggestions for future research, and all references is available electronically at the NASS Web site (www.spine.org) and will remain updated on a timely schedule.     

An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy

Background contextThe objective of the North American Spine Society's (NASS) Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy is to provide evidence-based recommendations to address key clinical questions surrounding the diagnosis and treatment of lumbar disc herniation with radiculopathy. The guideline is intended to reflect contemporary treatment concepts for symptomatic lumbar disc herniation with radiculopathy as reflected in the highest quality clinical literature available on this subject as of July 2011. The goals of the guideline recommendations are to assist in delivering optimum efficacious treatment and functional recovery from this spinal disorder.PurposeTo provide an evidence-based educational tool to assist spine specialists in the diagnosis and treatment of lumbar disc herniation with radiculopathy.Study designSystematic review and evidence-based clinical guideline.MethodsThis guideline is a product of the Lumbar Disc Herniation with Radiculopathy Work Group of NASS' Evidence-Based Guideline Development Committee. The work group consisted of multidisciplinary spine care specialists trained in the principles of evidence-based analysis. A literature search addressing each question and using a specific search protocol was performed on English-language references found in Medline, Embase (Drugs and Pharmacology), and four additional evidence-based databases to identify articles. The relevant literature was then independently rated using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final recommendations to answer each clinical question were developed via work group discussion, and grades were assigned to the recommendations using standardized grades of recommendation. In the absence of Level I to IV evidence, work group consensus statements have been developed using a modified nominal group technique, and these statements are clearly identified as such in the guideline.ResultsTwenty-nine clinical questions were formulated and addressed, and the answers are summarized in this article. The respective recommendations were graded by strength of the supporting literature, which was stratified by levels of evidence.ConclusionsThe clinical guideline has been created using the techniques of evidence-based medicine and best available evidence to aid practitioners in the care of patients with symptomatic lumbar disc herniation with radiculopathy. The entire guideline document, including the evidentiary tables, suggestions for future research, and all the references, is available electronically on the NASS Web site at http://www.spine.org/Pages/PracticePolicy/ClinicalCare/ClinicalGuidlines/Default.aspx and will remain updated on a timely schedule.     

An updated overview of clinical guidelines for the management of non-specific low back pain in primary care

The aim of this study was to present and compare the content of (inter)national clinical guidelines for the management of low back pain. To rationalise the management of low back pain, evidence-based clinical guidelines have been issued in many countries. Given that the available scientific evidence is the same, irrespective of the country, one would expect these guidelines to include more or less similar recommendations regarding diagnosis and treatment. We updated a previous review that included clinical guidelines published up to and including the year 2000. Guidelines were included that met the following criteria: the target group consisted mainly of primary health care professionals, and the guideline was published in English, German, Finnish, Spanish, Norwegian, or Dutch. Only one guideline per country was included: the one most recently published. This updated review includes national clinical guidelines from 13 countries and 2 international clinical guidelines from Europe published from 2000 until 2008. The content of the guidelines appeared to be quite similar regarding the diagnostic classification (diagnostic triage) and the use of diagnostic and therapeutic interventions. Consistent features for acute low back pain were the early and gradual activation of patients, the discouragement of prescribed bed rest and the recognition of psychosocial factors as risk factors for chronicity. For chronic low back pain, consistent features included supervised exercises, cognitive behavioural therapy and multidisciplinary treatment. However, there are some discrepancies for recommendations regarding spinal manipulation and drug treatment for acute and chronic low back pain. The comparison of international clinical guidelines for the management of low back pain showed that diagnostic and therapeutic recommendations are generally similar. There are also some differences which may be due to a lack of strong evidence regarding these topics or due to differences in local health care systems. The implementation of these clinical guidelines remains a challenge for clinical practice and research.     

Success of sentinel lymph node mapping after breast cancer ablation with focused microwave phased array thermotherapy

BACKGROUND: Breast cancer tumor ablation as part of a multimodality approach in the treatment of breast cancer is the subject of recent interest. This study was conducted to determine if the ability to perform sentinel node biopsy was impaired after thermal-induced ablation of breast cancer. METHODS: We studied patients who had sentinel node biopsy after preoperative focused microwave phased array for breast cancer ablation. RESULTS: Twenty-one patients with T1-T2 breast cancer and clinically negative axilla underwent wide local excision and sentinel node biopsy guided by blue dye and sulfur colloid. Surgery was done an average of 17 days after microwave ablation. Fifteen of 22 patients (68%) had histologic evidence of tumor necrosis. Sentinel lymph node mapping was successful in 19 of 21 patients (91%). Axillary metastases were detected in 42% of cases. CONCLUSIONS: This study documents successful sentinel lymph node mapping for patients treated with antecedent local tumor ablation using focused microwave phased array ablation.     

Outcome after hepatic resection versus combined resection and microwave ablation for multiple bilobar colorectal metastases to the liver

BACKGROUND: We investigated the efficacy of microwave ablation plus hepatectomy for multiple bilobar colorectal metastases to the liver. No consensus exists concerning local ablation plus hepatic resection for treating multiple bilobar colorectal liver metastases, partly because of a lack of long-term comparative survival data. METHODS: Clinicopathologic data were analyzed retrospectively for 53 consecutive patients with 5 or more bilobar liver metastases from colorectal cancer who underwent hepatectomy with or without microwave ablation. Outcome measures were recurrence rate, recurrence pattern, and survival. RESULTS: Combined resection/ablation was performed more frequently in patients with more liver metastases (P = .03). No significant differences were found for overall, disease-free, or hepatic recurrence-free survival between 16 patients with resection/ablation and 37 patients with resection (P = .43, .54, and .86, respectively). Multivariate analysis selected prehepatectomy carcinoembryonic antigen concentration in serum as an independent prognosticator for survival (P = .02), but not resection/ablation versus resection. In patients with combined resection/ablation, recurrence occurred near the resection or ablation line in only 2 patient (22%), whereas multiple neoplasms (>/=4) was the most common liver recurrence pattern (78%). CONCLUSIONS: Microwave ablation plus hepatic resection expanded indications for operation to treat multiple bilobar liver metastases, with survival similar to that in less-involved hepatic resection patients.